A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

Bradycardia.

Muffled heart sounds

Flattened neck veins.

Sudden lethargy.

Answer and Explanation

The Correct Answer is B

B. Muffled heart sounds, often described as distant or indistinct, are classic findings in cardiac tamponade. The accumulation of fluid in the pericardial sac dampens the transmission of sound from the heart to the chest wall, resulting in muffled heart sounds on auscultation. This finding is known as Beck's triad, which also includes hypotension and jugular venous distention.

A. Bradycardia is not a typical finding in cardiac tamponade. In fact, tachycardia is more commonly observed due to the compensatory response to decreased cardiac output and decreased stroke volume. The sympathetic nervous system is activated, leading to an increase in heart rate as a compensatory mechanism to maintain cardiac output.

C. Flattened neck veins are not consistent with cardiac tamponade. In cardiac tamponade, jugular venous distention (JVD) is typically observed due to increased venous pressure resulting from impaired right ventricular filling. The presence of JVD is an important clinical finding in cardiac tamponade and can help differentiate it from other causes of shock.

D. Sudden lethargy can occur in various medical emergencies, including cardiac tamponade, but it is not a specific or diagnostic finding for this condition. In cardiac tamponade, symptoms may include dyspnea, chest pain, hypotension, and signs of decreased cardiac output such as cool extremities and altered mental status. However, sudden lethargy alone may not be specific enough to confirm cardiac tamponade.

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Correct Answer is B

Explanation

B. The QT interval represents ventricular depolarization and repolarization. It starts at the beginning of the QRS complex and ends at the end of the T wave. The QT interval reflects the total time it takes for both ventricular depolarization and repolarization to occur. Prolongation of the QT interval can be associated with an increased risk of arrhythmias, including torsades de pointes.

A. The QRS complex represents ventricular depolarization, which is the electrical activation of the ventricles. The duration of the QRS complex provides information about the time it takes for ventricular depolarization to occur. A prolonged QRS complex can indicate abnormalities in ventricular conduction, such as bundle branch blocks or ventricular hypertrophy.

C. The ST segment represents the early part of ventricular repolarization. It starts at the end of the QRS complex and ends at the beginning of the T wave. Changes in the ST segment, such as elevation or depression, can indicate myocardial ischemia or injury.

D. The PR interval represents the time it takes for the electrical impulse to travel from the atria to the ventricles. It includes atrial depolarization, atrial contraction, and the delay at the atrioventricular node. The PR interval does not specifically provide information about ventricular depolarization and repolarization.

A. Initiation of continuous positive pressure ventilation (CPAP) B. Endotracheal intubation and positive pressure ventilation C. Insertion of a mini-tracheostomy with frequent suctioning D. Administration of 100% O2 by non-rebreather mask

Correct Answer is B

Explanation

B. Endotracheal intubation and positive pressure ventilation are indicated in patients with respiratory failure who are unable to maintain adequate oxygenation or ventilation with non-invasive interventions. Intubation allows for the delivery of positive pressure ventilation, oxygenation, and airway protection. It also facilitates the clearance of secretions and administration of medications. Given the patient's severe hypoxemia, impending respiratory distress, and deteriorating condition, endotracheal intubation and positive pressure ventilation are the most appropriate interventions to ensure adequate oxygenation and prevent further deterioration.

A. CPAP is a non-invasive ventilation modality that provides a continuous positive pressure to the airways throughout the respiratory cycle. While CPAP may be beneficial in certain cases of respiratory failure, it may not be sufficient for a patient with severe hypoxemia (SpO2 of 80%) and impending respiratory distress. CPAP is typically indicated for patients with conditions such as obstructive sleep apnea or mild to moderate respiratory failure.

C. Mini-tracheostomy may be considered in certain cases of upper airway obstruction or inadequate airway clearance. However, in this scenario, the patient's hypoxemia is likely due to severe respiratory failure rather than upper airway obstruction. While suctioning may be necessary to clear secretions, it does not address the underlying cause of hypoxemia or provide ventilatory support.

D. While administration of supplemental oxygen is important in the management of hypoxemia, a non- rebreather mask may not be sufficient for a patient with severe hypoxemia and impending respiratory distress. Non-rebreather masks can deliver high concentrations of oxygen but may not provide adequate positive pressure support or airway protection. In this case, endotracheal intubation and positive pressure ventilation are more appropriate to ensure adequate oxygenation and ventilation.

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A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

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